[104-10224-10000.pdf — page 87]
SECRETINDICATE, BY SIGNING YOUR INITIALS IN THE SOCIATE FOL BIOW THI RECEIVE PLAD THE EXPLANATIONS ANDCONSIDER THE MATTER CAREFULLY YO CHANGE, TYPE OF ANNUITY YOU WANT HA II YOU WANT AN ANNUITY WITH A SUAVIVOR BENEFIT, RE FILMED AFTER AN ANNUITY HAS BEEN GRANITYPES OF ANNUITY, MARRIED APPLICANTS ONLY1 ANNUITY WITH SURVIVOR BENEFIT TOWIDOW OR WIDOWER.*   If you are **married**, you will receive this type of annuity unless    you choose the annuity in G. 2SPECIFY THE PORTION OF ANNUITY YOU WANT USED AS THE BASEFOR YOUR WIDOWS*   The annuity payable to you during your lifetime will be reduced    by the amount of money used as the base for the survivor benefit plus 1%, of any amount over $1,000 so    used.> [Figure: An arrow pointing to a box with instructions to fill in]If you want all your annuity used as the base for the survivorbenefit, write the word *all* in the box below. If you wantonly part of your annuity used as the base for the survivorbenefit, write the parity amount of your annuity you want used.*   If you retire, for total disability before age 60 and get a years    of minimum disability annuity. You may use all or any part    of your annuity as the base for the survivor benefit. You cannot use any extra annuity which may be payable to make    up the guaranteed minimum annuity.*   Your wife for husband should die before you, no change in    type of annuity will be permitted; your annuity will not be in    creased, nor may you name any other person as survivor.*   The survivor's annuity will begin upon your death and end when    she for her dies or remarries.2.  ANNUITY WITHOUT SURVIVOR BENEFIT*   If you choose this type, your wife for husband cannot be paid    a survivor annuity after my death.*   This type provides annuity payments to you only.G. TYPES OF ANNUITY: UNMARRIED APPLICANTS ONLY (Including Widowed and Divorced)1. ANNUITY WITHOUT SURVIVOR BENEFIT*   If you are not married, you will receive this type of annuity    unless you choose the annuity in G. 2*   This type provides annuity payments to you only.2. ANNUITY WITH SURVIVOR BENEFIT TO   NAMED PERSON HAVING AN INSURABLE   INTEREST*   This type is available to all retiring unmarried employees who are    in good health.*   It provides a reduced annuity to you and a survivor annuity to    the person named as having an insurable interest.*   The survivor's annuity will begin upon your death and end when    the for her dies.SPECIFY THE NAME, RELATIONSHIP AND DATE OF BIRTH OF THE PERSON YOU WISHTO RECEIVE THE SURVIVOR ANNUITYNAME OF PERSON (Last, middle, first)RELATIONSHIP DATE OF BIRTH (Mo., day, yr.)*   The survivor's annuity will be 55% of the reduced annuity you    receive.*   If you choose this type, you will have to undergo a medical    examination which will be arranged by the Director of Personnel at no cost to you.*   If the person named as having an insurable interest should die    before you, no change in type of annuity will be permitted; your    annuity will not be increased, nor may your name any other    person as survivor.PARCINGORMATION REGARDING SURVIVORANNUITIES ON THE ATTACHED PLANATION OF MONCIN YOUR ANH. CERTIFICATION OF APPLICANTWARNING. Any intentional false statement in this applicationor willful misrepresentation relative thereto is a violation of thelaw punishable by a fine of not more than $10,000 or imprisonmentof not more than 5 years or both (18 U. S. C. 1001).I hereby certify that all statements made in this application are trueto the best of my knowledge and belief.I. FOR OFFICE OF PERSONNELSECRET![signature of applicant]